1、Improving the Glasgow Coma Scale score: motor score alone is a better predictor.下载全文 加入收藏夹 点击:2 下载:0 被引： BACKGROUND: The Glasgow Coma Scale (GCS) has served as an assessment tool in head trauma and as a measure of physiologic derangement in outcome models (e.g.,TRISS and Acute Physiology and Chronic
2、 Health Evaluation), but it has not been rigorously examined as a predictor of outcome. METHODS: Using a large trauma data set (National Trauma Data Bank, N = 204,181), we compared the predictive power (pseudo R2, receiver operating characteristic ROC) and calibration of the GCS to its components. R
3、ESULTS: The GCS is actually a collection of 120 different combinations of its 3 predictors grouped into 12 different scores by simple addition (motor m + verbal v + eye e = GCS score). Problematically,different combinations summing to a single GCS score may actually have very different mortalities.
4、For example, the GCS score of 4 can represent any of three mve combinations: 2/1/1 (survival = 0.52), 1/2/1 (survival = 0.73), or 1/1/2 (survival = 0.81). In addition, the relationship between GCS score and survival is not linear, and furthermore, a logistic model based on GCS score is poorly calibr
5、ated even after fractional polynomial transformation. The m component of the GCS, by contrast, is not only linearly related to survival, butpreserves almost all the predictive power of the GCS (ROC(GCS) = 0.89, ROC(m) = 0.87; pseudo R2(GCS) = 0.42, pseudo R2(m) = 0.40) and has a better calibrated lo
6、gistic model. CONCLUSION: Because the motor component of the GCS contains virtually all the information of the GCS itself, can be measured in intubated patients, and is much better behaved statistically than the GCS, we believe thatthe motor component of the GCS should replace the GCS in outcome pre
7、diction models. Because the m component is nonlinear in the log odds of survival, however, it should be mathematically transformed before its inclusion in broaderoutcome prediction models.BACKGROUNDWe investigated Glasgow Coma Scale (GCS) scores, intracranialpressure (ICP) and cerebral perfusion pre
8、ssure(CPP) changes, and long-term clinical outcomes in patientswith severe traumatic brain injury (STBI) associated withbilateral non-reactive dilated pupils (BNDP) who underwentdecompressive surgery (DS).我们调查了进行了减压手术的严重颅脑外伤（STBI）病人（双侧瞳孔散大）中GCS，ICP，CPP（灌注压）的结果METHODSThe study group consisted of 28 p
9、atients (11 females, 17males) with BNDP from among 147 patients who underwentDS due to STBI in our department.此项研究包括了双瞳孔散大的28例病人（11女，17男）（从147例因严重脑创伤进行了减压手术的病人选出）RESULTSThe mean GCS score was 4.961.20 at admission and 4preoperatively. Mean ICP in non-surviving patients afterDS was higher (p2 at admi
10、ssion was associated with lowermortality (p4)，平均ICP在非存活组在术后更高（PL2有更低的死亡率（P25 mmHg after DS despite conventionalICP controlling measures such as infusion of hyperosmoticsolution, hyperventilation, and CSF drainage.Seven (25%) surviving patients had a poor outcome(GOS score 2 or 3), whereas four (14.2
11、8%) survivingpatients had a good outcome (GOS score: 4 and5) (Table 1). In surviving patients, GCS scores at admissionwere higher than in non-surviving patients(p30 mmHg and/or a reduction in CPPto 2 at admission was associated with lowermortality. All surviving patients with a good outcomewere asso
12、ciated with initial GCS scores of 6 and 7.In our previous report, we already proposed that thisgroup of patients were the best candidates for DS.35They also presented with neurological deterioration(GCS score of 4 and BNDP) due to mass effect from ahematoma (subdural hematoma in 4 and intracerebralh
13、ematoma in 2 patients). Those patients might have ahigher chance of survival and functional recovery thanpatients whose neurological status is mainly caused bydiffuse cerebral swelling. The overall mortality rate inour patients who underwent DS with a GCS score of 4associated with BNDP in the preope
14、rative period was61.02%.Another important issue in SHI is management ofCPP.36-39 CPP is a physiological parameter intimatelylinked with ICP and mean arterial blood pressure, andit is the greatest determinant of cerebral hemodynamicresponses and effects. CPP management directs therapyto the pressure
15、gradient across the brain rather thanisolated ICP. However, recent, emphasis has movedagain to ICP because episodes of neuro-worseninghave been shown to be associated with ICP increasesand not changes in CPP.10,38,40 In our patient studygroup, CPP changes were not found significantly importantbefore
16、 and after DS. However, ICP was significantlydecreased in surviving patients compared tonon-surviving patients.In conclusion, the accurate prediction of outcomein patients with BNDP after SHI remains elusive, andthe outcome may not always be fatal or poor. RapidDS may increase the chance of function
17、al survival,especially in patients with admission GCS score of 6or 7 and neurological deterioration due to mass effectfrom a hematoma. In addition, this study raises highconcerns regarding the possibility of saving a patientfrom death, only for them to survive with severe disabilityin spite of current methods of reducing ICP.
